Provider Demographics
NPI:1851530794
Name:PAK, SOON R (LAC, RN)
Entity Type:Individual
Prefix:MRS
First Name:SOON
Middle Name:R
Last Name:PAK
Suffix:
Gender:F
Credentials:LAC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20105 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2563
Mailing Address - Country:US
Mailing Address - Phone:718-423-8046
Mailing Address - Fax:718-423-4907
Practice Address - Street 1:20105 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2563
Practice Address - Country:US
Practice Address - Phone:718-423-8046
Practice Address - Fax:718-423-4907
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390528163W00000X
NY002792171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163W00000XNursing Service ProvidersRegistered Nurse